Lay Leader Training Registration Form

PATH LEADER TRAINING APPLICATION

Please fully complete this application and submit to , by :  By mail:  By email:  By fax:

Trainee Information Date: Name: Employer: Email Address: Daytime Phone:

Mailing Address:

County: Licensing Information - REQUIRED In order to conduct PATH Workshops, you must be affiliated with an organization that holds a current license with Stanford University. Please provide us with the contact information for the license holder you will be working with. Agency Name: Contact Name: Contact Phone: Contact Email:

Mailing Address:

1. Are you willing to attend a 4-day leader training and complete all training activities required to be certified as a Leader for the Stanford Chronic Disease Self-Management Program (called PATH in Michigan)?

PATH Leader Training Application Revised January 9, 2014 Page 1 of 3  Yes  No

2. Will you be available in the six (6) months immediately following training to conduct one (1) PATH workshop (6 weeks, for 2 ½ hours each week)?  Yes  No

3. PATH workshops require you to speak in front of groups and write on a white board. Are you comfortable performing these activities?  Yes  No

4. PATH Workshops must be led by two trained leaders or master trainers. Do you know who you will be working with to conduct workshops?  Yes  No

5. Please list any volunteer, work or life experience you have had that you believe make you a good candidate for this training:

6. What are your reasons for wanting to participate in a leader training?

7. Are you a health professional? Yes  No If yes, please list your credentials (i.e. MA, LPN, MD) and briefly describe your work:

8. PATH leaders generally either have a chronic condition or live with someone who has a chronic condition. Does this apply to you? Yes  No If yes, please describe:

9. Please describe any barriers or challenges that could interfere with you becoming a leader and meeting all of the requirements that have been described in these application materials

PATH Leader Training Application Revised January 9, 2014 Page 2 of 3 (e.g., energy, time, transportation, availability, limitations resulting from your own or another’s chronic conditions).

10. What are the counties or communities in which you would be willing to serve as a leader?

Your signature on this application indicates that you will do your best to meet the conditions listed below.  I agree to teach at least one (1) PATH workshop in the six (6) months following the training.  I agree to register workshops, collect participant evaluation and demographic data according to the guidelines provided by Michigan Partners on the PATH, including the required PATH Attendance Log.  I agree to conduct the program according to Stanford program guidelines and requirements. I will maintain program fidelity and will not change the program in any way without prior authorization from Stanford University.  I agree to keep information discussed during the training and workshops confidential.

Signature of Applicant Date

Special Accommodations: Please indicate any special accommodations you may need at the training. Deadline to request accommodations is . If requests are received after this date, we will do our best to accommodate your needs but cannot be guaranteed.

THANK YOU for your interest! All applications will be reviewed.

Questions? Contact

PATH Leader Training Application Revised January 9, 2014 Page 3 of 3